19364 vs. S2068 for DIEP/SIEP Flaps
Q. There’s been ongoing confusion in our office regarding the proper coding of deep inferior epigastric perforator flap (DIEP) for breast reconstruction. Should we be using HCPCS Level II code S2068, or CPT® 19364? May we also code separately for partial rib resection (21600) when performed as part of the reconstruction?
A. The American Medical Association (AMA) addressed this issue in a “Bonus Feature: Special Q&A,” in the December 2011 CPT® Assistant:
Q. Should code 19364, Breast reconstruction with free flap, be used to report the performance of a deep inferior epigastric perforator flap (DIEP) for breast reconstruction?
A. Yes. Code 19364, Breast reconstruction with free flap, is the appropriate code to report free flap breast reconstruction, regardless of the specific free flap used. It may be a free transverse rectus abdominis myocutaneous (TRAM), a free DIEP, or a gluteal free flap. Code 19364 is not limited to a particular type of free flap, and it is the code to be used to report any type of free flap breast reconstruction.
Code 19364 includes harvesting of the flap, microvascular transfer (one artery and two veins), closure of the donor site, and transfer to the chest and inset, including the creation of the breast mound. Examples are a free transverse rectus abdominis myocutaneous (TRAM) flap, a free DIEP, or free gluteal flap. Microvascular transfer includes the use of the operating microscope. Code +69990 Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure) is
not reported in conjunction with code 19364.
The AMA also takes a position that a DIEP flap (and a superficial inferior epigastric artery (SIEA) flap), as described by 19364, includes partial rib resection. This was clarified in the March 2013 CPT® Assistant:
Q. May code 21600, Excision of rib, partial, be reported separately, in conjunction with breast reconstruction, when performed with a free flap?
A. No. CPT code 19364, Breast reconstruction with free flap, includes a partial rib resection and thus, code 21600 is not reported separately. Code 19364 includes the creation of a pocket, preparation of recipient vessels, harvest and transfer of flap to the recipient site, partial rib resection, microvascular anastomosis of one artery and two veins, closure of the donor site, and primary closure.
Based on the recent AMA clarifications, S2068 Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral is now redundant (although it remains “on the books” as an active HCPCS Level II code). You should report S2068 only if your payer/contract specifically calls for its use. Note that S codes, including S2068, are never payable by Medicare.